DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Recurrent umbilical fistula tract, probable stitch abscess.
POSTOPERATIVE DIAGNOSIS: Infected preperitoneal umbilical hernia mesh with recurrent fistula.
OPERATION PERFORMED:
1. Umbilical fistulectomy with reconstruction of the umbilicus.
2. Excision of infected preperitoneal abdominal wall mesh.
3. Ventral herniorrhaphy with primary closure.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient brought into the surgical suite and placed on the operating table in a supine position. The patient was anesthetized and easily endotracheally intubated. After adequate analgesia and anesthesia had been obtained, SCDs were present bilaterally for DVT prophylaxis and an orogastric tube was placed for gastric decompression. Levaquin 500 mg was given intravenously, preoperatively, for antibiotic prophylaxis. The abdomen was shaved, prepped and draped in the usual sterile manner using Betadine solution.
A 3 cm curvilinear incision in the infraumbilical fold was performed to the old scar. This was carried down to the dermis, subcutaneous tissue to the infraumbilical anterior rectus sheath. The subcutaneous fat was dissected off the anterior rectus sheath superiorly. Palpation of the umbilicus to its depth revealed a fistulous tract originating beneath the fascia and infected underlying anterior abdominal Kugel patch of mesh. The umbilicus was separated from the fistulous tract and reconstruction of the umbilicus was performed, excising the fistulous tract and approximating the skin edges using 3-0 Vicryl sutures with excellent closure of the umbilicus. The entire umbilicus and surrounding adipose tissue was separated from the anterior rectus sheath.
An approximately 1.5 cm fistulous tract was noted at this level and this extended beneath the fascia. The fascia was divided in the midline superiorly and inferiorly down to the preperitoneal space. Upon entering the preperitoneal space, the infected Kugel patch mesh was noted. This was circumferentially excised, including the fistulous tracts and 0 Ethibond sutures, which held it in place. The entire infected anterior abdominal wall mesh was excised and sent to Pathology as a specimen, leaving approximately a 4.5 cm deficit of the anterior abdominal wall. The abdomen was entered since the mesh was attached to the peritoneum and excised. No injury to the underlying bowel could be noted. The bowel appeared to be viable. A small abscess cavity had formed in this area with adhesion on the bowels together in this area. Adhesiolysis was performed and the area was opened.
The wound was copiously irrigated using 2 liters of normal saline with clear effluence of fluid. Excellent hemostasis was assured. Due to the infected area, foreign body mesh could not be placed back within the incision. The fascia was approximated transversely using 0 Prolene and a figure-of-eight stitch interrupted sutures with excellent approximation of the fascia. Subcutaneous tissues were copiously irrigated and a stab incision on the right lateral abdomen was performed and a J-Vac was placed through this incision and into the wound and secured to the skin using 2-0 nylon. The dermis was approximated using 3-0 Vicryl and skin staples were used to approximate the skin edges. A dry sterile dressing was applied.
The patient was reversed from anesthesia, extubated on the operating table and transferred to postanesthesia recovery in stable condition. All instrument, needle and sponge counts were correct x3 at closure. The patient tolerated the procedure well.
